situational analysis of cervical cancer prevention …
TRANSCRIPT
SITUATIONAL ANALYSIS OF
CERVICAL CANCER PREVENTION AND CONTROL
IN THE CARIBBEAN
Results from a 2013 assessment of country policies and services
for HPV vaccination, cervical cancer screening, diagnosis and treatment
December, 2013
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SITUATIONAL ANALYSIS OF CERVICAL CANCER PREVENTION AND CONTROL IN THE CARIBBEAN
Table of Contents Executive Summary ____________________________________________________________ 4 Background ___________________________________________________________________ 5 Introduction __________________________________________________________________ 6 Methods _____________________________________________________________________ 7
Cervical cancer incidence and mortality ________________________________________ 7 Human Papilloma Virus (HPV) prevalence in the Caribbean __________________________ 7 Caribbean cervical cancer program assessment ___________________________________ 7 Results_______________________________________________________________________ 8
Cervical cancer incidence ____________________________________________________ 11 Cervical cancer mortality ____________________________________________________ 12 HPV prevalence ___________________________________________________________ 13 Status of cervical cancer programs ____________________________________________ 15 Civil society role in the Caribbean _____________________________________________ 30
Conclusions __________________________________________________________________ 31
ANNEX 1. Respondents to the Caribbean Cervical Cancer Program Assessment ___________________ 32 2. Studies of HPV infection prevalence in selected Caribbean countries ___________________ 33 TABLES 1. Overview of country information. 2. Overview of cervical cancer in selected non-Latin Caribbean countries. 3. Relevant demographic information for cervical cancer programs. 4. Summary of cervical cancer incidence in selected non-Latin Caribbean countries. 5. Cervical cancer mortality in selected non-Latin Caribbean countries. 6. Cervical cancer policies, programs and guidelines in selected non-Latin Caribbean countries. 7. Status of HPV vaccination in national immunization programs. 8. Cervical cancer screening services available in the public sector. 9. Available services for diagnosis and treatment of pre-cancerous cervical lesions. 10. Available services for invasive cancer treatment and palliative care. 11. Health human resources available for cervical cancer. 12. Monitoring of cervical cancer prevention programs. 13. General assessment of cervical cancer program. 14. Civil society response.
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ACKNOWLEDGEMENTS
This report was prepared by Damali Martin1, Silvana Luciani and Elisa Prieto, with input from Maisha
Hutton and Tomo Kanda. The authors wish to thank the following individuals who provided information
used in this report: Grüngberg Antoon, Marie Louise Baker, Natalia Largaespada Beer, Homer
Bloomfield, Vikash Chatrani, Tamu Davidson, Angela C Desabaye, Hilda Dunsmmore, Petrinella Edwards,
Maria Henry, Laura Tucker Longsworth, Fiona llegall, Naomi D Prince, Gerty Surena, Rhonda Simmons,
and Sook Lee Yin. The Ministries of Health of non-Latin Caribbean countries were an active partner in
providing data relevant for this report. The Healthy Caribbean Coalition was a major partner in the data
collection process working in concert with their Caribbean Cancer NGO membership, who were fully
engaged and worked with the Ministry of Health partners.
___________________
1 while on assignment to the Pan American Health Organization from the National Cancer Institute’s Center for Global Health
and Division for Cancer Control and Population Sciences.
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EXECUTIVE SUMMARY
Cervical cancer remains a significant public health concern in the Caribbean where it is the second
leading cause of cancer deaths among women. This report synthesizes the available information on
cervical cancer incidence, mortality and HPV prevalence in the non-Latin Caribbean countries, as well as
summarizes the results of a survey of national cervical cancer program managers regarding the current
capacity and status of cervical cancer programs.
Among the countries in the non-Latin Caribbean, all have established cervical cancer screening, based on
cytology as part of public health programs, and 3 countries have already introduced HPV vaccines into
their national immunization programs. Information is lacking in most countries, however on the
screening coverage and proportion of women with abnormal screening test results receiving follow up
diagnosis and treatment, which are key indicators for program effectiveness. Furthermore, limitations
in health human resources and infrastructure, especially for radiotherapy, present challenges to
improving program effectiveness. Despite these limitations, cervical cancer program managers from
Ministries of Health report that there exists a high political interest in addressing cervical cancer and
that it was feasible their government will provide funding to strengthen screening services and
introduce HPV vaccines in the near future. Civil society organizations, including the Healthy Caribbean
Coalition, are playing an important role in the Caribbean to raise public awareness and participation in
screening programs and advocate for more government investments for cervical cancer prevention and
control.
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BACKGROUND
Cervical cancer is a major cause of morbidity and mortality among women worldwide. Among Caribbean
women of all ages, cervical cancer is the second most common cancer in terms of incidence and
mortality and accounts for 13% of all cancer cases and 10.4% of all cancer deaths 1.
Cervical cancer, caused by persistent infection with human papillomavirus (HPV), is a highly preventable
disease. Vaccines against HPV are available to prevent infections. Screening women for precancerous
cervical lesions can detect early stages of the disease, and when treated, will prevent progression to
invasive cervical cancer. Despite this fact, cervical cancer prevention and control is a challenge and
remains a significant public health concern in the Caribbean.
To address this problem, the Pan American Health Organization/World Health Organization
(PAHO/WHO) developed the Caribbean Cervical Cancer Prevention and Control Project in 2001. The
project supported the countries of the non-Latin Caribbean to enhance their capacity to implement
organized, targeted and sustained programs for cervical cancer prevention and control2. A number of
initiatives were undertaken through the project, including development of screening and treatment
policies and guidelines, evaluating screening programs, training cytologists to improve quality of
cytology testing, and a social communication and advocacy campaign to raise awareness of the cervical
cancer problem among women. Building on this work, PAHO/WHO created the Regional Strategy and
Plan of Action for Cervical Cancer Prevention and Control in Latin America and the Caribbean which was
endorsed by Ministers of Health throughout the Americas in 2008. It aims to strengthen cervical cancer
program effectiveness, through a seven point plan of action, across the continuum of care from primary
prevention, screening, treatment, palliative care and including cancer registration3.
This report presents the results of the situation assessment of the current capacities for cervical cancer
prevention and control in the non-Latin Caribbean countries. It was prepared, in part to fulfill one point
of the Cervical Cancer Regional Strategy, namely the conduction of a situation assessment; and to
further assist the non-Latin Caribbean countries with better understanding the strengths, needs and
gaps in their national cervical cancer programs. The Healthy Caribbean Coalition, HCC, was a major
partner in the data collection process for this report, working in concert with their Caribbean Cancer
NGO membership.
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INTRODUCTION This situational analysis of cervical cancer prevention and control in the non-Latin Caribbean provides an overview of the current policies, programs and services in place. The objective is to synthesize individual country information to support strengthening programs. This report presents information on the cervical cancer incidence and mortality from 2000 to latest year available, as well as a snapshot of HPV vaccine introduction, cervical cancer screening, diagnosis, treatment, palliative care, program monitoring and cancer registration. A total of 18 countries are included in this report. Table 1 summarizes the country and data reported in this analysis. TABLE 1: OVERVIEW OF COUNTRY INFORMATION
Country Cervical cancer incidence data
(Year)
Cervical cancer mortality data
(Year)
HPV prevalence
studies (Year)
Cervical cancer program
assessment (Year)
Program screening
coverage (Year)
Antigua and Barbuda ●
(2000 - 2008)
Aruba ●
(2000 - 2004; 2006 - 2008)
●
(2007)
Bahamas ●
(1988 - 2002)
● (2000 - 2003; 2006 - 2008)
Barbados ●
(2000 - 2004; 2006 - 2008)
● (1993)
● (2013)
● (2008)
Belize ●
(2011) ●
(2000 - 2008) ●
(2007) ●
(2013)
Bermuda ●
(2012)
● (2000 - 2002;
2004; 2006 -2008)
● (2012)
Cayman Islands ●
(2005 - 2012)
● (2013)
● (2012)
Dominica ●
(2007 - 2011) ●
(2003 - 2008)
● (2013)
● (2008)
Grenada ●
(2000 - 2004; 2006 - 2008)
Guyana ●
(2000 - 2007) ●
(2000 - 2008) ●
(2004 - 2008) ●
(2013)
Haiti ● ●
(2013)
Jamaica ●
(2003 - 2007) ●
(2006)
● (1990, 1993, 2006, 2010)
● (2012)
St. Kitts and Nevis ●
(2011) ●
(2000 - 2008)
● (2013)
● (2008)
St. Lucia ●
(2000 - 2005; 2008)
●
(2012)
St. Maarten ●
(2013)
St. Vincent and the Grenadines
●
(2000 - 2008)
● (2012)
Suriname ● ●
(2000 - 2008) ●
(1992-1995) ●
(2012)
Trinidad and Tobago ●
(2000 - 2002) ●
(2000 - 2008)
● (2004; 2007;
2012)
● (2013)
● (2011)
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METHODS
Cervical cancer incidence and mortality
Incidence data from the non-Latin Caribbean countries were obtained from an extensive literature search using Pub Med and Google Scholar, with the search terms cervical cancer, cervical cancer incidence, cancer and Caribbean, cancer registries, cancer registration and cervical cancer. Scientific articles and reports published from 2003-2012 were reviewed. Mortality data were extracted from the PAHO/WHO mortality database for 14 countries from the non-Latin Caribbean which routinely provide data from their national vital registration systems, available for 2000-2012. These countries include: Antigua and Barbuda, Aruba, The Bahamas, Barbados, Belize, Bermuda, Dominica, Grenada, Guyana, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Suriname, and Trinidad and Tobago. ICD-10 coding for deaths from uterine cervix (ICD-10 C53) was used to identify cervical cancer mortality cases in each country. All countries did not have complete data for the time period of this analysis, and Table 1 indicates the years of data available. Age-standardized cervical cancer mortality rates were calculated using female population specific age groups for women aged 15-75+ years, and calculated weights of the world standard population [6]. Given the small population size in these countries, and thus low number of annual deaths from cervical cancer, age-standardized mortality rates were calculated using 3 year periods 2000-2002, 2003-2005, 2006-2008. HPV prevalence An extensive literature search was performed on HPV prevalence in the non-Latin Caribbean using Pub Med and Google Scholar with the search terms human papillomavirus in Caribbean, human papillomavirus prevalence in the Caribbean, human papillomavirus genotypes and Caribbean, high-risk human papillomavirus in Caribbean. Studies published in 1993-2013 were reviewed. Caribbean cervical cancer program assessment Information was gathered from cervical cancer program managers in Ministries of Health, and in some countries, from the civil society organization as well. Information on demographics and burden of disease, cervical cancer prevention and control policies and programs, HPV vaccination, screening, cervical cancer treatment and palliative care, cervical cancer monitoring and evaluation, and human resources was collected using a structured questionnaire. The questionnaire was sent to Ministries fo Health in January, 2012 and for those who did not complete the 2012 survey, were sent the same questionnaire in February, 2013. The Healthy Caribbean Coalition, HCC, was a major partner in the data collection process for the 2013 questionnaires, working in concert with their Caribbean Cancer NGO membership. Information was gathered by Cancer NGOs (see Annex 1) in preparation for a 2013 Caribbean regional meeting aimed at building capacity of civil society organizations (CSO) for evidence informed advocacy on cervical cancer. Data was collected using participatory approaches in which the CSOs were fully engaged and worked with local PAHO representatives and Ministry of Health partners to complete the questionnaires as part of a larger process of generating evidence to inform advocacy. The process: built cervical cancer policy and programming awareness among CSOs; created and strengthened relationships between CSOs and national governments working together to achieve a shared objective, in particular in those settings where cancer NGOs play a significant role in the provision of cervical cancer related prevention, treatment and care; and highlighted priority gaps and needs for advocacy.
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RESULTS The detailed results to the cervical cancer program assessment, by each responding country are provided in this section and Table 2 provides the highlights of the main results. Demographic data
The relevant demographic data needed to plan cervical cancer prevention and control programs, are
described in Table 3. Women account for roughly half of the total populations for all responding
countries and women age 25 – 64, the target population for cervical cancer screening are indicated in
Table 3 below. Girls aged 9 – 12 years; an age group of interest for HPV vaccination is also included.
TABLE 3: RELEVANT DEMOGRAPHIC INFORMATION FOR CERVICAL CANCER PROGRAMS
Country Total
Population Number of women aged 25-64 years
Number of girls aged 9-12 years
Barbados 286,705 83,688 18, 000
Belize 324,300 64,749 15,431
Bermuda 69,100 19,685 1,469
Cayman Islands 52,600 18,379 1,201
Dominica 72,969 NR 8,188
Guyana 756,040 168,727 90, 000
Haiti 10,123,787 2,020,638 1,149,000
Jamaica 2,761,300 653,992 299, 000
St Kitts & Nevis 50,314 22,135 4,430
St. Maarten 38,486 17,280 1385
St Vincent & Grenadines
103,500 22,440 10,000
Suriname 534,200 125,090 19,740
Trinidad & Tobago
1,351,000 357,364 41,300
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TABLE 2: OVERVIEW OF CERVICAL CANCER IN SELECTED NON-LATIN CARIBBEAN COUNTRIES
Country Population
size HPV Prevalence (reference)
Number of new cervical cancer cases
(Year)
Number of cervical cancer deaths
(Year)
HPV vaccine introduction
Screening services
Pre-cancer treatment services
Cancer registry
Antigua and Barbuda
88,000 n/a n/a 25 (2000 - 2008) n/a n/a n/a n/a
Aruba 106, 000 n/a n/a 38
( 2000-2004; 2006-2008)
n/a n/a n/a n/a
Bahamas 347,000 n/a n/a 91
(2000-2003; 2006-2008)
n/a n/a n/a Hospital-
based
Barbados 286,705
HPV DNA was identified in 90% of the samples of histologically confirmed carcinoma (n = 20). HPV 16 was present in 65% samples, HPV 33 and 45 were present in 5%. (11)
n/a 121
(2000 - 2004; 2006 - 2008)
September 2013
Pap smear, HPV DNA test
Colposcopy, Cryotherapy, LEEP and Cold Knife Conization
Population-based
Belize 324,300
The prevalence of high-risk genotypes was 15.6% in a sample of 463 women from general population, 10.1% in those women with normal cytology, 93% in women with HSIL. (12)
38 (2011)
109 (2000 - 2008)
n/a Pap smear, VIA Colposcopy, LEEP,Cold
Knife Conization n/a
Bermuda 69,100 n/a 15
(2012)
10 (2000 - 2002; 2004;
2006 - 2008) n/a
Pap smear, HPV DNA test
Colposcopy, LEEP, Cold Knife Conization
Population-based
Cayman Islands 52,600 n/a 12
(2005 - 2012) n/a 2012
Pap smear, VIA, HPV DNA test
Colposcopy, Cryotherapy, LEEP, Cold Knife Conization, Single
visit VIA followed by cryotherapy
Population-based
Dominica 72,969 n/a 81
(2007 - 2011) 31
(2003 - 2008) n/a Pap Smear
Colposcopy, Cryotherapy, Cold Knife Conization, Single visit
VIA followed by cryotherapy
n/a
Grenada 108,000 n/a n/a 34
(2000 - 2004; 2006 - 2008)
n/a n/a n/a n/a
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Guyana 756,040
Among study sample of Amerinidian women, prevalence of HPV was 19.5% for all women, 11% in women with normal cytology. (13)
573 (2000 - 2007)
327 (2000 - 2008)
2012 Pap smear, VIA
Colposcopy, Cryotherapy, LEEP,
Single visit VIA followed by cryotherapy
Population-based
Haiti 10,123,787 n/a n/a n/a n/a VIA Cryotherapy, Single visit VIA followed by
cryotherapy n/a
Jamaica 2,761,300
HPV prevalence for any genotype was 54%. Oncogenic HPV genotypes were found in 34.9% of the total study population. (17)
302 (2003 - 2007)
133 (2006)
n/a Pap Smear
Colposcopy, Cryotherapy, LEEP, Cold Knife Conization, Single
visit VIA followed by cryotherapy
Population-based
St. Kitts and Nevis
50,314 n/a 14
(2011) 14 (2000 - 2008) n/a Pap smear, VIA Colposcopy, CKC n/a
St. Lucia 162, 000 n/a n/a 118
(2000 - 2005; 2008) n/a n/a n/a n/a
St. Maarten 38,486 n/a n/a n/a n/a Pap Smear n/a n/a
St. Vincent and the Grenadines
103,500 n/a n/a 70
(2000 - 2008) n/a Pap smear, VIA
Colposcopy, Cryotherapy, LEEP, Cold Knife Conization, Single
visit VIA followed by cryotherapy
n/a
Suriname 534,200
HPV prevalence was 82% in 258 women with malignant cervical lesions (n=130). HPV 16 and 18 were the most common genotypes. (18)
1138 (1980 - 2004)
235 (2000 - 2008)
n/a Pap smear, VIA
Colposcopy, Cryotherapy, LEEP,
Single visit VIA followed by cryotherapy
Hospital-based
Trinidad and Tobago
1,351,000
HPV prevalence was 40.6% for both low-risk and high-risk HPV. In addition, 65.9% of HPV positive women were infected with high-risk HPV. (20)
324 (2000 - 2002)
598 (2000 - 2008)
January 2013
Pap smear, VIA, HPV DNA test
Colposcopy, LEEP Population-
based
n/a= information not available
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CERVICAL CANCER INCIDENCE Data on cervical cancer incidence from the non-Latin Caribbean are scarce, but the literature review yielded several studies summarized in Table 4 below. TABLE 4: SUMMARY OF CERVICAL CANCER INCIDENCE DATA AVAILABLE FROM NON-LATIN CARIBBEAN
Country (reference) Year(s) Number of new
cervical cancer cases (age group)
Cervical cancer incidence rates
(age group)
Grand Bahama, The Bahamas4
1988 - 2002 58
(27 – 77 years) 60/100,000
(27 – 77 years)
Belize (survey) 2011 38
(21-55 years) 54.9/100,000
(21 to 55 years)
Bermuda5 1991 - 2003, 2012 15
Caucasian 5.8/100,000 (n/a)
Black 7.6/100,000 (n/a)
Cayman Islands (survey) 2005-2012 12
(n/a) n/a
Dominica (survey) 2007-2011 81
(21 - 70+ years) n/a
Guyana6 2000 - 2007 573
(< 70 years) n/a
Jamaica (Kingston & St. Andrews area)7
2003 - 2007 302 17.4/100,000
(20 - 85+ years)
St. Kitts and Nevis (survey) 2011 14
(n/a) n/a
Suriname8, 9 1980 - 2004 1138
(all ages)
Urban 12/100,000 (all ages)
Rural 10/100,000 (all ages)
Trinidad and Tobago10 2000-2002 324
(25 - 85+ years) 16.5/100,000
(25 - 85+ years)
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CERVICAL CANCER MORTALITY
Cervical cancer mortality rates differ among the countries included in this analysis (Table 5). From 2000
to 2002 and from 2003 to 2005, Belize, St. Lucia and St. Vincent and the Grenadines reported the
highest burden for cervical cancer mortality. Dominica also reported high cervical cancer mortality
(23.6/100,000) from 2003 to 2005. From 2006 to 2008, Dominica, Guyana and St. Vincent and the
Grenadines reported the highest cervical cancer mortality rates for the region. For all three time
periods, Bermuda reported the lowest mortality rate for cervical cancer.
TABLE 5: CERVICAL CANCER MORTALITY IN SELECTED NON-LATIN CARIBBEAN COUNTRIES
Country
Cervical cancer mortality among women aged 15 years and older
2000 - 2002 2003 - 2005
2006 - 2008
No. ASMR No. ASMR No. ASMR
Antigua and Barbuda 6 7.6 10 11.6 9 9.3
Aruba 14 10.7 a12 a 12.4 12 7.2
Bahamas 44 14.5 b14 b13.8 33 8.9
Barbados 56 16.2 c34 c12.8 31 7.3
Belize 39 25.4 35 20.5 35 17.0
Bermuda 5 4.7 d1 d3.2 4 2.8
Dominica n/a n/a 14 23.6 17 21.7
Grenada 8 11.0 e8 e9.6 18 17.7
Guyana 108 19.5 112 20.8 107 19.0
St. Kitts and Nevis 4 8.4 6 10.0 4 7.4
St. Lucia 52 34.2 56 34.6 f10 f12.5
St. Vincent and the Grenadines 27 30.0 22 20.2 21 19.4
Suriname 70 16.3 76 16.7 89 17.7
Trinidad and Tobago 181 13.6 201 14.0 216 14.1 Notes: a Aruba is missing data for 2005; b. Bahamas is missing data for 2004 – 2005; c. Barbados is missing data for 2005; d. Bermuda is missing data for 2003 and for 2005; e. Grenada is missing data for 2005; f. St Lucia is missing data for 2006 - 2007.
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HPV PREVALENCE The following countries have conducted HPV prevalence studies in various populations over the past 10-15 years: Barbados, Belize, Guyana, Jamaica, Suriname and Trinidad and Tobago. A synthesis of the results of these various studies is presented below and summarized in Table 2. Note that the results are not comparable across countries, given the differences in study populations and/or sample size of study population, changes in specimen collection over time, and differences in HPV DNA testing methods. Appendix 1 contains a detailed summary of these HPV prevalence studies.
Barbados
HPV prevalence study was performed in 1993 in paraffinized tissue from twenty Barbadian women with
genital carcinoma that was verified histologically. HPV DNA was identified in 90% of the samples. HPV
16 was present in 65% samples, HPV 33 and 45 were present in 5%11.
Belize
HPV prevalence study was performed in 2007 on 463 women as part of a campaign on cervical cancer
prevention. Hybrid Capture 2 (HC2) testing was performed and samples that tested positive were then
processed further for low and high risk HPV genotypes. The prevalence of high-risk genotypes was
15.6% in total population and 10.1% in those women with normal cytology. Approximately 93% of
women diagnosed with high grade cervical squamous intraepithelial lesion (HSIL) had high-risk HPV
present in their cervical samples. The most frequent HPV genotypes present in the study population
was 16, 18, 56 and 52. In addition, HPV 16 and 18 were the most common genotypes for women with
normal cytology and 47% of women with HSIL were positive for HPV 1612.
Guyana
One HPV prevalence study was performed on the indigenous or Amerindian women in Guyana from
2004 to 200813. For this study, over 2200 Amerindian women between 13 and 84 years were screened
for cervical cancer and over 1400 women between 13 and 80 years were screened for HPV prevalence.
The mean age for the women tested for HPV prevalence was 36.9 years. Approximately 19.5% of the
women tested were HPV positive. HPV prevalence was 11% among women with normal cytology
results, in agreement with the global prevalence of HPV among women with normal cytology. A nested
study of HPV genotyping was performed on 44 women with cervical intraepithelial neoplasia (CIN) II/III
or invasive cancer. The predominant genotypes were HPV 31, 16 and 52 among women with CINII/III
(n=35), whereas HPV 18, 16, 31 and 39 were the predominant genotypes among the women with
invasive cervical cancer (n=9).
Jamaica
Four various HPV prevalence studies have been conducted in Jamaica14-17. The most recent HPV
prevalence study is described here17. This study was performed on 852 sexually active women, age 16
– 49 years, who attended a selected public or private primary health clinic in one of the four health
authority regions. HPV prevalence for any genotype was 54%. HPV prevalence was highest among the
women who were younger (71.9% in women 16 – 19 years) compared to the older study subjects (42.6%
in women 40 – 49 years). Oncogenic HPV genotypes were found in 34.9% of the total study population,
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and HPV 16 was the predominant genotype. Oncogenic HPV were found in30.6% of women who had a
normal cytology test . Furthermore, 84% of women with abnormal cytology test were HPV positive. The
prevalence of HPV 16 and d 18 was higher in the subgroup of women with HSIL compared to those with
lower severity of abnormality (LSIL, ASCUS or normal).
Suriname
One study examined the prevalence and distribution of HPV genotype in a population of 258 women
with malignant cervical lesions, from Suriname and the Netherland18. Data from the Surinamese
population was collected from 1992 to 1994, and from the Netherland population from 1992 to 1995.
HPV prevalence was found in 82% of samples from Suriname (n = 130) compared to 87% of samples
from the Netherlands (n = 128). HPV 16 (49% and 68% in Suriname and the Netherlands, respectively)
and 18 (15% and 16% in Suriname and the Netherlands, respectively) were the predominant subtypes in
both populations. No significant differences for the prevalence of HPV 16 and 18 distribution were
observed among Creoles, Hindustani and Javanese patients.
Trinidad and Tobago
Three various HPV prevalence studies have been conducted in Trinidad & Tobago19-21. One study in
2007 investigated HPV prevalence in 310 women who attended three primary health care centers in the
northern part of Trinidad. HPV prevalence was 40.6% for both low-risk and high-risk HPV. In addition,
65.9% of HPV positive women were infected with high-risk HPV. HPV 52, 66 and 16 were the
predominant genotypes (12.7%, 10.3% and 9.5%, respectively). In addition, approximately 30% of HPV
positive subjects had multiple HPV infections. HPV prevalence was higher in the younger age group
compared to the oldest age groups20.
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STATUS OF NATIONAL CERVICAL CANCER PROGRAMS Policies and programs Table 6 presents a summary of cervical cancer policies and programs available in each of the 13 countries who responded to the program assessment questionnaire. TABLE 6: CERVICAL CANCER POLICIES, PROGRAMS AND GUIDELINES IN SELECTED NON-LATIN CARIBBEAN
Country
Policy for
cervical cancer
Program for
cervical cancer
Program manager
for cervical cancer
Work plan to
implement cervical cancer
program
Budget for
cervical cancer
program
Clinical guidelines/protocols
for cervical cancer
Treatment capacity
Treatment for precancerous
lesions
Treatment of invasive
cancer Palliative care
Barbados No No No No No No Yes Yes NR
Belize Yes Yes Yes Yes Yes Yes Yes Yes NR
Bermuda No No No No No Yes Yes Yes Yes
Cayman Islands Yes Yes No Yes No No Yes Yes Yes
Dominica NR Yes Yes Yes No Yes Yes Yes Yes
Guyana Yes Yes No Yes NR Yes Yes Yes Yes
Haiti No No No No No Yes Yes NR NR
Jamaica No Yes Yes Yes No Yes Yes Yes Yes
St Kitts & Nevis No No No No No No Yes NR NR
St. Maarten No No No No No No Yes Yes NR
St Vincent & Grenadines
Yes Yes Yes No No Yes Yes Yes Yes
Suriname Yes No No No Yes Yes Yes Yes No
Trinidad & Tobago
NR Yes No Yes No Yes Yes Yes Yes
NR=no response
Five countries responded as having a cervical cancer policy in place: Belize, the Cayman Islands, Guyana, St. Vincent and the Grenadines and Suriname. Seven countries reported having an organized cervical cancer screening program: Belize, the Cayman Islands, Dominica, Guyana, Jamaica, St. Vincent and the Grenadines and Trinidad and Tobago. Suriname reported that, while there is no program, a draft national strategic plan exists which includes instituting a national program and integrating cervical cancer screening into the basic health care services. All countries, with the exception of the Cayman Islands and St. Kitts and Nevis, reported having clinical guidelines and protocols in place. In addition, all countries reported having a referral system for women who need follow up treatment for precancerous lesions; whereas eleven countries reported that they have a referral system for women who need treatment for invasive cancer. However, only seven countries reported a referral system for women who need palliative care. Only Belize and Suriname reported having a budget specifically for cervical cancer; and 4 countries [Belize, Dominica, Jamaica and St. Vincent and the Grenadines] reported having a cervical cancer
16
program manager. However, it is not clear if these program managers are involved in other aspects of women’s health, cancer or non-communicable disease programs in general. Barbados, Belize, Dominica and St. Kitts and Nevis reported that they are considering a change or reviewing the current cervical cancer policies and programs. Barbados reported that future plans include decreasing the frequency of screening and increasing screening intervals, whereas St. Kitts and Nevis reported that they are considering an integrated approach to screening (additional details was not provided). Belize reported that they plan to strengthen the current program in order to increase coverage of its target population. HPV vaccination Table 7 summarizes countries’ status of HPV vaccine introduction. Of the countries responding to the survey, 3 noted they had already introduced HPV vaccines into their national immunization programs [Cayman Islands, Guyana, Trinidad & Tobago]. The Cayman Islands and Guyana reported that HPV vaccines were introduced in 2012, while Trinidad and Tobago reported they introduced HPV vaccines in January, 2013. All 3 countries reported that they administer HPV vaccines to females ages 10-13 years. However, the Cayman Islands reported that HPV vaccination is administered to girls up to age 18 years. In addition, all 3 countries indicated using schools or district health clinics to deliver the HPV vaccines. Several countries indicated that they plan to introduce HPV vaccines into their national immunization program in the near future. Barbados reported planning to begin in September, 2013.Belize, Dominica and Suriname provided plans for pre-introduction of the HPV vaccine. Belize indicated that they plan to perform a cost-effectiveness study for the introduction of the vaccine. Dominica reported plans to investigate HPV prevalence within its population and to include HPV genotyping as part of its study. Two countries, St. Kitts and Nevis and Haiti, reported that at present there are no plans for HPV vaccination.
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TABLE 7: STATUS OF HPV VACCINATION IN NATIONAL IMMUNIZATION PROGRAMS
Countries
HPV vaccination part of national immunization
program
Information on HPV vaccination program If no, are there plans to include HPV vaccination
into national immunization program?
Year started Target sex
and age group
Vaccination setting
Barbados Yes Scheduled
to start 2013
11 years of age
Entry into secondary
school NA
Belize No NA NA NA Yes
Bermuda No NA NA NA Yes
Cayman Islands
Yes 2012 Females
11-18 years of age
High schools and district
clinics NA
Dominica No NA NA NA Yes
Guyana Yes 2012 Females
10-13 years of age
Schools and health clinics
NA
Haiti No NA NA NA No
Jamaica No NA NA NA Yes
St Kitts & Nevis
No NA NA NA No
*St. Maarten No NA NA NA Yes
St Vincent & Grenadines
No NA NA NA Yes
Suriname No NA NA NA Yes
Trinidad & Tobago
Yes 2013 Females
11-12 years of age
Clinics and school
NA
NA=information not available
Screening Table 8 summarizes the reported cervical cancer screening services for each of the 13 country who responded to the survey. With regards to available screening tests, all countries reported that they offer Pap smears, except Haiti. VIA screening (visual inspection with acetic acid) is reported in eight countries [Belize, Cayman Islands, Guyana, Haiti, St Kitts & Nevis, St Vincent & the Grenadines, Suriname and Trinidad & Tobago]. HPV testing within the public health system was reported in four countries [ Barbados, Bermuda, Cayman Islands, Trinidad & Tobago]. Suriname, St. Vincent and the Grenadines, Jamaica and Belize reported that HPV DNA testing is not offered within their public health sector. However, Suriname reported having the technology to perform HPV testing and current testing performed as part of studies are not included as part of the routine screening practices. Jamaica reported that HPV DNA testing is available from the private health services.
18
Public health education programs that promote and educate women about the importance of cervical cancer screening were noted as being in place in almost all responding countries, except Barbados, St. Kitts and Nevis, and Suriname. These programs are mostly led by the Ministries of Health or other government entities, health or family planning clinics and other non-governmental organizations (NGOs), such as cancer societies. It is important to note that respondents indicated that private sector also participates in cervical cancer screening education and promotion in Bermuda, Dominica, Jamaica and Trinidad and Tobago. For example, Bermuda reported that pharmaceutical companies have been involved in ongoing social mobilization and education efforts in their country. Belize noted that cervical cancer education and screening promotion is limited due to budget constraints and under-staffing. TABLE 8: CERVICAL CANCER SCREENING SERVICES AVAILABLE IN THE PUBLIC SECTOR
Country
Screening tests are available in primary
care services Screening frequency Target population Cost of screening for patient
Programs to promote cervical cancer
screening
Pap VIA HPV Pap VIA HPV Pap VIA HPV Pap VIA HPV
Barbados Yes NR Yes
Every 3 years, 21-49 years Every 5
years, 50-65 years
NR NR Women 21 - 65 years
NR NR Full/Partial
/Free NR Full No
Belize Yes Yes No
Yearly until 3
consecutive
negative test, then
every three years
NR NA Women 21 - 55 years
Women 21-
55 years
NA Free Free
NA
Yes by MOH, Belize Family Life, private
sector
Bermuda Yes No Yes
Every 2 years for women 20-30 years
Every 3 years for women > 30 years
NA
Repeat after 12
months if monitoring ASCUS
> 20 years NA
Women with ASCUS
diagnosis
Full/partial NA Full/partia
l
Yes by the Department
of Health, Bermuda
Cancer and Health Centre, Government
TV, public radio
broadcasts, Merck and
GSK
Cayman Islands
Yes Yes Yes Every 2 years
Evaluate abnorm
al pap
NR NR
15 years and
older
NR Partial Partial
Partial
Yes by Health Services
Authority, Cayman
Islands Cancer Society, other
civil society
Dominica Yes NR NR NR NR NR Women 15 to 59
years NR NR Free NR NR
Yes by MOH, Cancer Society,
physicians, planned
parenthood,
19
faith-based organizations
Guyana Yes Yes NR NR NR NR
Women who are sexually active
Women age
25-49 years
NR Full Free
NA
Yes by MOH/ Cancer
Institute, Local
organization
Haiti NR Yes NR NR NR NR NR NR NR NR NR NR
Yes by MOH, Family Health Ministries and
GSCC
Jamaica Yes No No
Once every 3 years
once two consecuti
ve pap smears
are normal
NA NA Women 25-54 years
NA NA Free NA NA Yes
St Kitts & Nevis
Yes Yes NR
Annually for 1st
two tests, then once
every 3 years with
normal results
NR NR
All sexually active
females
NR NR Free NR NR No
*St. Maarten
Yes NR NR NR NR NR NR NR NR Full/partial NR NR
Yes by Ministry of
Public Health, Social
Development and Labour
with Ministry of General
Affairs, NGO
St Vincent & Grenadines
Yes Yes No
Two intial negative
tests, one year apart
then every 3 years
NR NR Women 20-65 years
NR NR Full Full NA
Yes by MOH, Cancer society
and Agency for Public
Information
Suriname Yes Yes No Every 2 years
Every 2
years
NA
Post-menopau
sal women
Women 23-
55 years
NA Full/partial
Full/partia
l
NA No
Trinidad & Tobago
Yes Yes Yes Once
every year NR NR
Available for all
women NR NR Free
Free
Free
Yes by Sexual and
reproductive programmes,
Population programme
Unit, EPI programme
NA=not available; NR=no response
20
Screening guidelines Cytology (Pap test): Barbados, Bermuda, Belize, Dominica, Jamaica and St. Vincent and the Grenadines reported that they target both pre-menopausal and post-menopausal women for cytological screening of cervical cancer with ages ranging from 15 to 65 years. St. Kitts and Nevis and Guyana reported that they target all sexually active women, whereas Trinidad and Tobago indicated that cytology screening was available for all women. Countries varied in their responses for recommended cytology screening intervals. Trinidad and Tobago reported yearly screening for their targeted population, whereas Suriname and the Cayman Islands reported that they recommend screening every two years. Barbados and Bermuda indicated that they follow the screening guidelines outlined by The American Congress of Obstetricians and Gynecologists (ACOG), which indicates longer screening intervals for older populations. For examplein Bermuda, reported screening intervals for cervical cancer is every two years for women ages 20 to 30 years, but every three years for women greater than 30 years. Belize, Jamaica, St. Vincent and the Grenadines and St. Kitts and Nevis reported that they screen their target population every three years after the first two or three yearly or consecutive negative tests. VIA screening guidelines: Belize, Guyana and Suriname reported that their VIA screening guideline cover women aged 21 – 55 years, 25 – 49 years and 23 – 55 years, respectively. However, the Cayman Islands reported they include 15 year and older in their guideline for VIA screening, which is used not as a primary screening test, but as a followup test of abnormal Pap smears.With regards to VIA screening interval, Suriname was the only respondent and noted that VIA screening is recommended every two years in their guidelines. HPV testing guidelines: The countries responding to having HPV testing in place did not provide specific information on their guidelines. Bermuda indicated that HPV testing is used to monitor women who have a Pap test result of atypical cells of undetermined significance (ASCUS). In this population, women undergo HPV testing immediately and 12 months after initial diagnosis. Screening program coverage With regards to Pap screening coverage, 7 countries [Barbados, Belize, the Cayman Islands, Jamaica, St. Kitts and Nevis, St. Vincent and the Grenadines and Suriname] provided responses. Reported coverage ranged from 8% (St. Vincent and the Grenadines) to greater than 85% (Cayman Islands). All of these countries reported falling short of their targeted coverage, which ranges from25% (St. Vincent and the Grenadines) to 100% (Barbados). For VIA screening, Suriname was the only country to report information. They noted that the coverage of their target population is less than 15%, which falls short of their targeted coverage of 80%. Follow up on abnormal screening test results With the exception of the Cayman Islands, none of the countries were able to report information on the percentage of women with an abnormal screening test result who received follow up diagnosis and treatment (if indicated). The Cayman Islands have reported that 97% of women with an abnormal Pap test result are followed up for further evaluation and treatment. Suriname indicated that recent data of follow up was not available, yet they reported that 35% of women received complete follow up and treatment during a National Pap Smear Project from 1998 - 2001.
21
Cost of screening to women With regards to costs to women for screening services, cytology testing was reported as free of charge in 6 countries [Barbados, Belize, Dominica, Jamaica, St. Kitts and Nevis and Trinidad and Tobago]. However, Barbados indicated that women could also provide full or partial payment for cytology. Guyana and St. Vincent and the Grenadines reported that women obtaining cytology screening services pay for the services in full. Other countries stated that cytology screening can range from partial payment (provided that the woman is insured) to full payment. For example, Suriname reported that women who are insured (80% of the population) provide partial co-payment for their cytology test, whereas women who are uninsured will pay in full. VIA screening services are reported free of charge in 3 countries:Belize, Guyana and Trinidad and Tobago. The Cayman Islands reported that women provide partial payment, whereas St. Vincent and the Grenadines reported that women provide full payment. Suriname indicated that the cost for VIA services could be full or partial and depends on the patient’s insurance status. For HPV DNA testing, Barbados indicated that women pay in full for this test, whereas Bermuda indicated that women make either partial or full payment. Diagnosis and Treatment of pre-cancer Table 9 summarizes the available services for diagnosis and treatment of pre-cancerous cervical lesions.
22
TABLE 9: AVAILABLE SERVICES FOR DIAGNOSIS AND TREATMENT OF PRE-CANCEROUS CERVICAL LESIONS
Country
Available services Laboratory services
Colposcopy Cryotherapy LEEP Cold Knife Conization
VIA followed by cryotherapy
No. cytology
labs
Number of pap smears processed
in past year
Internal quality control
External quality control
Information system
Y/N Number Cost to patient
Y/N Cost to patient
Y/N Cost to patient
Y/N Cost to patient
Y/N Cost to patient
Barbados Yes 1 Free Yes Free Yes Free Yes Free No NA 1 NR Yes Yes Yes
Belize Yes 4 US $80 No NA Yes Partial Yes Partial NR NR 2 6,565 No Yes Yes
Bermuda Yes 1 US $525 No NA Yes Full Yes Full No NA 1 NA NA NA Yes
Cayman Islands
Yes 3 CI $300 Yes Full Yes Full Yes Full Yes Full 1 2,500 Yes Yes Yes
Dominica Yes NR EC $150 Yes EC $250 NR NR Yes EC $510 Yes EC $250 1 2,149 Yes Yes Yes
Guyana Yes NR Free Yes Free Yes Free NR NR Yes Free 1 1,926
(2010-2013) Yes NR Yes
Haiti No NA NA Yes NR NR NR No NA Yes NR 1 NA No No No
Jamaica Yes 5 Free Yes Free Yes Free Yes Free Yes Free 3 32,774 Yes Yes Yes
St Kitts & Nevis
Yes 2 NR No NA No NA Yes Full No NA 1 2,203 Yes Yes Yes
St. Maarten NR NR NR NR NR NR NR NR NR NR NR 0 NA NA NA NA
St Vincent & Grenadines
Yes NR NR Yes NR Yes NR Yes NR Yes NR 1 NR Yes No No
Suriname Yes 1 - 2 Unknown Yes Partial Yes NR NR NR Yes Free 2 2,684 Yes No Yes
Trinidad & Tobago
Yes NR Free NR NR Yes NR NR NR NR NR 4 NR NR NR No
NA=not available; NR=no response
23
Cytology laboratory All countries, with the exception of St. Maarten reported having public health laboratories for processing cytology tests. The reported number of government laboratories range from 1(most countries) to as many as 4 (Trinidad and Tobago). The reported number of cytology test processed in the previous year ranged from 2,203 (St. Kitts and Nevis) to 6,565 (Belize). Guyana reported that 1,926 cytology tests were processed over the past three years. Eight countries also indicated the presence of private cytology laboratories. The reported number of private laboratories ranged from 1 (Dominica, Guyana and the Cayman Islands) to 8 (Jamaica). Barbados, Bermuda and the Cayman Islands also reported that the number of pap smears processed within the private sector is 1,253, 3,000 and 2,186, respectively. Internal quality control procedures for cytology were reported in 9 countries [Barbados, the Cayman Islands, Dominica, Guyana, Jamaica, St. Kitts and Nevis, St. Vincent and the Grenadines and Suriname]. Furthermore, Barbados, Belize, the Cayman Islands, Dominica, Jamaica and St. Kitts and Nevis reported having external quality control procedures. All countries except Haiti, St. Vincent and the Grenadines and Trinidad and Tobago indicated that they have an information system for cytology tests within their laboratories and that this system also includes information from the private sector. VIA screening, followed by cryotherapy treatment A single visit screen and treat approach, using VIA screening followed by cryotherapy treatment was reported as being offered in 7 countries [The Cayman Islands, Dominica, Guyana, Haiti, Jamaica, St. Vincent and the Grenadines and Suriname]. Yet,only 3 [Guyana, Jamaica and Suriname]reported that the procedure was free for all patients. The Cayman Islands reported that the patient is required to provide the full payment, but did provide information on the exact cost. Dominica reported a cost of EC$250 (approx. US$675). The Cayman Islands, Guyana, Jamaica and Trinidad and Tobago also stated that the procedure is offered in their private health sector Colposcopy services Public sector colposcopy services were reported as available in almost all countries surveyed. All countries reported having at least one type of treatment for pre-cancerous lesions,cryotherapy, LEEP, or cold knife conization available within their public health care system, with the exception of St. Maarten. All these procedures are available in Barbados, the Cayman Islands, Jamaica and St. Vincent and the Grenadines. A few of the countries who reported offering coloscopy , also provided information on the number of available colposcopes, which ranged from 1 (Barbados and Bermuda) to 5 (Jamaica). Colposcopy services are reported as free of charge in Barbados, Guyana, Jamaica and Trinidad and Tobago. Cost for colposcopy procedure in Belize, Cayman Islands, Dominica and Bermuda is US$80, CI$300 (approx. US$366), EC$150 (approx. US$405) and US$525, respectively. Eight countries reported that colposcopy was also offered in the private health sector. The reported number of colposcopes available in the private sector ranged from 1 (Bermuda) to 7 (Cayman Islands) and the number of colposcopes in both sectors, the reported number of colposcopes available in the private sector was equal or greater in all cases. In most cases, the reported cost of the procedure was also higher in the private health sector. For example, the reported cost of colposcopy in the private sector in Barbados could range from US$150 to US$300.
24
Cryotherapy Eight countries, namely Barbados, Cayman Islands, Dominica, Guyana, Haiti, Jamaica, St. Vincent and the Grenadines and Suriname indicated that they offer cryotherapy.In those countries reporting costs, cryotherapy treatment was reported as free of charge to women in Barbados, Guyana and Jamaica. The Cayman Islands reported that patients are required to provide the full cost, but did not provide information on the cost of service to the patient. Dominica reported that cryotherapy services cost EC$250 (approx. US$675). Suriname indicated that the cost of cryotherapy depends on country location and medical insurance status. Specifically, cryotherapy was reported as being free for women who lived in the interior areas of Suriname. However, for other women, cryotherapyis partially or fully covered for women who have medical insurance coverage. Eight countries reported that cryotherapy is also offered in the private sector and patients will make either full or partial payments. LEEP Ninecountries indicated that they offer loop electrosurgical excision procedure (LEEP). St. Kitts and Nevis does not offer LEEP procedure and Dominica, St. Maarten and Haiti did not provide information. Barbados, Guyana and Jamaica reported that this procedure is free to patients within the public health sector. Bermuda and Cayman Islands stated that women are required to pay in full, whereas Belize indicated that some insurance coverage is provided and only partial payment is required. None of these countries provided information on the exact cost for the procedure. Ten countries reported that LEEP treatment is also offered in the private sector. In all cases, it was reported that patients are required in pay in full, but exact costs were not provided. Cold knife conization Eight countries indicated that they offer cold knife conization in their public health care sectors. Haiti reported that this procedure is not offered, whereas Guyana, St. Maarten, Suriname and Trinidad and Tobago did not provide information. Barbados and Jamaica reported that this procedure is free. Belize reported that partial payment by the patient is required for this procedure. Bermuda, Cayman Islands and St. Kitts and Nevis reported that patients are expected to provide full payment. The patient’s out-of-pocket cost was not provided for those countries who reported partial or full payment. Dominica reported that cold knife conization procedure will cost EC$510 (approx. US$1377) and patients are expected to cover the entire costs for the procedure. Nine countries also reported that cold knife conization is offered in the private sector and full payment is required. Treatment and palliative care for invasive cervical cancer Nine countries [Barbados, Belize, Dominica, Guyana, Jamaica, Haiti, St Kitts & Nevis, St Vincent & Grenadines, Trinidad & Tobago] indicated that gynecologists are available to perform radical hysterectomy in the public sector.
25
TABLE 10: AVAILABLE SERVICES FOR INVASIVE CANCER TREATMENT AND PALLIATIVE CARE
Country Gynecologist to perform radical hysterectomy
Availability of chemotherapy
Availability of radiotherapy
Availability of palliative care
Barbados Yes Yes Yes Yes, not
coordinated
Belize Yes NR Not available Yes, but not structured
Bermuda Not available Yes Not available Yes
Cayman Islands
Not available Yes Not available Yes
Dominica Yes Yes Not available Yes, but not structured
Guyana Yes Yes Not available Only symptomatic
treatment, not palliative
Haiti Yes Yes, but drugs are
brought from overseas Not available
Yes, but small unit at General Hospital
Jamaica Yes Yes, at four regional
hospitals
Yes, available at one hospital. Out dated
technology and long waits
Yes, one facility. Free for patients
St Kitts & Nevis
Yes Not available Not available Yes, pain
management and home care
St. Maarten Not available Yes, referred to
specialists either locally or abroad
Yes, referred to specialists either locally
or abroad Not available
St Vincent & Grenadines
Yes Not available Not available Not available
Suriname Not available Yes Yes, since early 2012 at
the Centre for Radiotherapy
Yes, provided by Homecare
organizations
Trinidad & Tobago
Yes Yes, at one centre Yes NR
NR=no response
Chemotherapy Chemotherapy is available in ten countries, though Haiti indicated that chemotherapy drugs are usually imported from other countries. Belize, St. Kitts & Nevis, and St. Vincent and the Grenadines reported that chemotherapy was not available. Dominica offers chemotherapy at a cost to the patient. In
26
Guyana, chemotherapy is provided to the patient free of cost as along as the patient is part of the Georgetown Public Health Clinics (GPHC). Patients, who are not part of the public health system in Guyana, are required to purchase the chemotherapy drugs. If a patient cannot afford to purchase chemotherapy drugs, they are referred to the GPHC, but waiting periods could be as long as a month. In Trinidad and Tobago, chemotherapy obtained by a patient in the private sector will be subsidized by the Government. Radiotherapy Radiotherapy is not available in most countries that responded to the survey. Only five countries, namely Barbados, Jamaica, St. Maarten, Suriname and Trinidad and Tobago, indicated that they have radiotherapy services. However, Jamaica has indicated difficulties in administrating radiotherapy as their equipment is outdated. In Jamaica, radiotherapy is available at one facility with up to date technology in Kingston. In Guyana, radiotherapy is available in the Cancer Institute of Guyana, which collaborates with the Guyanese Ministry of Health to provide radiotherapy to patients who are part of the public system. Dominican patients in need of radiotherapy are sent to Barbados. Palliative care Eight countries offer palliative care to patients diagnosed with cervical cancer in the public health sector. The Cayman Islands reported that palliative care is well developed in both public and private health sectors. In Suriname, palliative care is offered by home care organizations and is supervised by the patient’s family doctor. In Belize, health care professionals provide palliative care in collaboration with the Belize Cancer Society, but palliative care is not very well structured. Barbados and Dominica also reported that palliative care treatment is not well-structured or coordinated. In Dominica, clients are mostly supported by family members and the Dominica Cancer Society. In Haiti and Jamaica, only one facility offers palliative care publicly. However, it should be noted that palliative care in Jamaica is free. In addition, three other sites within Jamaica offer palliative services at a cost to the patient. In Guyana, patients that are part of the public health sector are offered symptomatic treatment and not palliative care. However, palliative care is offered at the private hospital or at the patients’ home by a private foundation. Unfortunately, palliative care is not available in St. Vincent and the Grenadines. Health human resources for cervical cancer control A summary of available human resources is shown in Table 11. With regards to the public health sector, all thirteen countries reported that they have gynecologists. Seven countries reported that they have radiotherapists and eight countries reported that they have oncologists. In addition, four countries reportedly have gynecological oncologists and four countries indicated the presence of nurse oncologists. Furthermore, four countries stated that they have medical physicists; six countries indicated that they have palliative care specialists and six countries reportedly have pathologists. All countries except St. Maarten, indicated the presence of cytotechnologists. The reported number of trained cytology staff in the public health sectors ranged from one (Suriname and St. Vincent and the Grenadines) to ten (Barbados, Haiti and Jamaica). Continuous training for personnel (doctors, nurses, pathologists, cytotechnologists) involved in cervical cancer services are offered in Belize, the Cayman Islands, Guyana, Jamaica and St. Vincent and the Grenadines. Program Monitoring, Evaluation and Cancer Registries Table 12 summarizes program monitoring and provides information on cancer registration. Few countries reported having a cervical cancer program evaluation, and only the Cayman Islands and
27
Jamaica reported such evaluations. With regards to information systems, five countries [Belize, Guyana, Jamaica, St. Kitts and Nevis and St. Vincent and the Grenadines] indicated that an information system to track women in the screening program was available. TABLE 12: MONITORING OF CERVICAL CANCER PREVENTION PROGRAMS
Country Program
evaluation Cancer registry
Information system for follow-up
Unique identifiers
Barbados No Yes No No
Belize No No Yes Yes
Bermuda No Yes No No
Cayman Islands Yes Yes (Population-
based) No No
Dominica No No No No
Guyana NR Yes (Population-
based) Yes NR
Haiti No No No No
Jamaica Yes Yes (Population-
based) Yes No
St Kitts & Nevis No No Yes No
St. Maarten No No No No
St Vincent & Grenadines No No Yes Yes
Suriname No Yes No No
Trinidad & Tobago No Yes (Population-
based) No No
NR=no response
Cancer registries Seven countries report having cancer registries to track incidence and mortality [Barbados, Bermuda, Cayman Islands, Guyana, Jamaica, Suriname and Trinidad and Tobago], and four are reported as population-based. Unique patient identifiers are only available in Belize and St. Vincent and the Grenadines. In Belize, unique identification numbers are automatically generated by the Belize Health Information System and serves as an alternative to the social security number.
The cancer registry in Barbados is part of a larger registry which also collects information on other chronic non-communicable diseases, namely stroke and CVD22. Currently, cancer registration is retrospective and information on cancer incidence is currently being collected from previous years. This registry is housed within the Chronic Disease Center at the University of West Indies at Cavehill and is supported by the Ministry of Health in Barbados. The Bermuda National Tumour Registry is a population based cancer registry which was established in 1979. The cancer registry underwent restructuring in 2004 and was re-launched in 200823. The Cayman
28
Islands cancer registry is a population based cancer registry located at the government hospital and collects data on all identified cancers within the population of the Cayman Islands24. The Elizabeth Quamina Cancer Registry in Trinidad and Tobago was established in 1994 and serves as the national cancer registry for the island25. The Cancer Registry of Guyana, which was established in 2000, serves in the same capacity6. Both registries are housed within the Ministries for Health in their respective countries. The cancer registry in Jamaica is part of the Department of Pathology at the University of the West Indies at Mona, and covers 24% to 26% of the Jamaican population located in the St. Andrew and Kingston’s area7. The registry was established in 1958, making it the longest established registry within the English-speaking Caribbean. As reported on the situational survey, an additional registry is housed in the Western Regional Health authority and covers cancer incidence in that region, which accounts for 18% of Jamaica’s population. The cancer registry in Suriname is managed by the Pathologic Anatomy Laboratory of the Academic Hospital in Paramaribo and has collected information on histologically-confirmed cases of cancer since 1960. It is generally regarded as the national cancer registry of Suriname8, 9. Although not reported in the survey, The Bahamas has a hospital based cancer registry which is housed within the Princess Margaret Hospital and collects information on all cancer cases diagnosed in public health sector. General self assessment Respondents provided a general assessment of the status of cervical cancer programs in their country and results are presented in Table 13. Most respondents characterize the burden of cervical cancer in as high, as is the political interest in addressing cervical cancer. In addition, all of the respondents reported that it was feasible their government will provide funding to strengthen screening services for cervical cancer and this would likely occur in the coming years. In regards to the HPV vaccine, five countries believe that there is a high or moderate likelihood that their government was likely to fund its introduction. In addition, respondents noted the importance of civil society’s role in cancer prevention and control and rated civil societies’ response as satisfactory.
29
TABLE 13: GENERAL ASSESSMENT OF CERVICAL CANCER PROGRAM
Assessment High Moderate Low Unknown
Cervical cancer burden in country Belize, Dominica, Guyana, Haiti, Trinidad and Tobago
Barbados Cayman Islands,
St. Kitts and Nevis St. Maarten
Need for improving women's health services
Barbados, Belize, Guyana, Haiti, Trinidad and Tobago
Dominica, St. Kitts and Nevis, St.
Maarten Cayman Islands n/a
Need for improving adolescent health services
Barbados, Belize, Dominica, Guyana, St.
Kitts and Nevis, Trinidad and Tobago
St. Maarten Cayman Islands Haiti
Opportunities for receiving external and collaborating organization support
St. Kitts and Nevis, Trinidad and Tobago
Cayman Islands, Dominica and St.
Maarten
Barbados, Belize, Haiti
Guyana
Rating of current screening policies Cayman Islands Dominica, Guyana,
Trinidad and Tobago
Barbados, Belize, Haiti, St. Kitts and
Nevis, St. Maarten
n/a
Success of current screening policies
Cayman Islands, Dominica Barbados, Guyana,
Trinidad and Tobago Belize, Haiti, St.
Maarten St. Kitts and
Nevis
Rating of current adolescent immunization policies
Cayman Islands Guyana, St. Maarten
and Trinidad and Tobago
Barbados, Belize, Dominica, Haiti,
St. Kitts and Nevis n/a
Success of current adolescent immunization policies
Barbados, Belize, Cayman Islands
St. Maarten, Trinidad and Tobago
Dominica, Guyana, Haiti, St.
Kitts and Nevis n/a
Political interest in improving cancer control
Belize, Cayman Islands, St. Kitts and Nevis, Trinidad
and Tobago
Dominica, Guyana, Haiti, St. Maarten
Barbados n/a
Political interest in improving cervical cancer control
Belize, Cayman Islands, Haiti, St. Kitts and Nevis,
Trinidad and Tobago
Dominica, Guyana, St. Maarten
Barbados n/a
Likelihood of government funding for strengthening screening services
Belize, Cayman Islands, Haiti, Trinidad and Tobago
Barbados, Dominica, Guyana, St. Kitts and
Nevis, St. Maarten n/a n/a
Likelihood of government funding for introduction of the vaccine
Barbados, Cayman Islands, Guyana, St. Maarten, Trinidad and Tobago
Haiti Belize, Dominica St. Kitts and
Nevis
30
Feasibility of strengthening screening programs in the coming years
Belize, Cayman Islands, Dominica, Guyana, Haiti,
Trinidad and Tobago
Barbados, St. Kitts and St. Maarten
n/a n/a
Feasibility of introducing HPV vaccination programs in the coming years
Guyana, Haiti, St. Maarten, Trinidad and
Tobago
Barbados, Belize, Dominca
Cayman Islands, St. Kitts and Nevis
n/a
Current role of civil society in cervical cancer prevention, treatment and control
Cayman Islands Barbados, Dominica, Haiti, Trinidad and
Tobago
Belize, Guyana, St. Kitts and
Nevis, St. Maarten
n/a
Importance of civil society in cervical cancer prevention, treatment and control
Belize, Cayman Islands, Dominica, Guyana, St. Kitts
and Nevis, St. Maarten, Trinidad and Tobago
Barbados Haiti n/a
CIVIL SOCIETY IN THE CARIBBEAN Civil society actors were reported as providing services for cervical cancer in seven countries [Barbados, Belize, Cayman Islands, Dominica, Guyana, Haiti, St. Maarten]. In addition, five countries [Barbados, Cayman Islands, Dominica, Haiti, St. Maarten] indicated that civil society organizations are actively working in communications, social mobilization and advocacy. The Healthy Caribbean Coalition, a civil society alliance to combat chronic diseases, is mobilizing civil society actors around the issue of cervical cancer screening and treatment. To this end, they have launched a regional Civil Society cervical cancer advocacy initiative beginning with a regional advocacy capacity building workshop for 20 cancer societies representing 16 Caribbean countries. This was followed by the development of a Caribbean Cancer Alliance and the launch of the first of its kind Caribbean cervical cancer e-petition (CCCEP) calling on Heads of States to increase access to cervical cancer screening and treatment for Caribbean women. The HCC has also developed two tools for CSOs. 'The Caribbean Civil Society Cervical Cancer Advocacy Handbook and Planning Tool' is a practical tool for the design and implementation of community based cervical cancer advocacy initiatives; and 'Connecting Communicating, Collaborating, HCC Social Media 'How to" Guide' is a resource to strengthen NCD related eHealth and social media capacity among CSOs. As well, the HCC has recently conducted a mapping and prepared an extensive report of current cancer NGO efforts for cervical cancer prevention and control in the Caribbean. More information about the e-petition and the mapping report can be found on the HCC website: http://healthycaribbean.org/ TABLE 14: CIVIL SOCIETY RESPONSE
Yes No
Civil Society Organizations providing services related to cervical cancer
Barbados, Belize, Cayman Islands,
Dominica, Guyana, Haiti, St. Maarten
St. Kitts and Nevis
Civil Society Organizations working specifically in cervical cancer communication, social mobilization
and advocacy
Barbados, Cayman Islands, Dominica, Haiti, St. Maarten
Belize, St. Kitts and Nevis, Trinidad and
Tobago
31
CONCLUSION
Cervical cancer is a significant public health burden in the Caribbean region, where it is the second most
common cancer and cause of cancer deaths among women. While incidence data is scarce from this
region, cervical cancer incidence varies among the non-Latin Caribbean countries. Mortality data, from
the countries included in this analysis also varied. From 2006 to 2008, cervical cancer mortality ranged
from 2.8/100,000 to 21.7/100,000. These data may be underestimated for issues related to
completeness of data collection, coding, and accuracy of pathological diagnosis. Introduction of new
cancer registries and the improvements to current cancer registries is necessary to gain a more accurate
understanding of the burden of cervical cancer, especially incidence.
This analysis illustrates the level of capacity available for cervical cancer screening, diagnosis, treatment
and palliative care in several Caribbean countries. The human and infrastructural resources are notably
greater in the larger countries such as Jamaica and Trinidad and Tobago, yet several of the smaller
countries, such as the Cayman Islands and St. Vincent and the Grenadines offer a range of services. Of
urgent need, however, is to improve radiotherapy capacity which has limited availability.
HPV vaccine introduction has not reached its full potential in this region, with only a limited number of
countries including these vaccines into their national immunization programs. Perhaps one of the
greatest challenges in this region, however, is the limited capacity of cytology laboratories to meet the
demands needed for a high screening coverage, acceptable turn around time for Pap test results, and
quality control. In this regard, HPV DNA testing and VIA screening, as well as single visit VIA screening
followed by cryotherapy treatment can offer viable solutions to address the cytology problem. Yet, few
countries in this region are fully embracing these new technologies into their cervical cancer screening
policies, and programs in a systematic manner.
Most countries were unable to report data on their current screening program coverage, and in addition
were not able to provide information on the percentage of women receiving follow up diagnosis and
treatment. For those who did report, current coverage rates were very low, which has implications for
the effectiveness of the program. This calls attention for the need for information systems with unique
patient identifiers to follow up women and ensure connection of all levels of the health care system.
The limited human resources is also a challenge. Although most countries have gynecologists, other
specialized personnel such as cytologists, radiotherapists, oncologists and gynecological and nurse
oncologists are very limited. In addition, most countries do not have continuous training programs that
provide up to date health information to their health personnel.
Despite these numerous challenges, countries responding to this cervical cancer program assessment
note that political will exists to improve access to HPV vaccination, screening and treatment, and that
civil society actors are playing a critical role in cervical cancer prevention and control. This indicates the
potential to improve the effectiveness of programs, and save more women’s lives in the Caribbean.
32
ANNEX 1: RESPONDENTS TO THE 2012 – 2013 NON-LATIN CARIBBEAN CERVICAL CANCER PROGRAM ASSESSMENT SURVEY
Country Name Position Organization
Date completed questionnaire
Barbados Vikash Chatrani Senior
registrar/Director
Queen Elizabeth Hospital /Barbados Cancer
Society
7-Mar-13
Bermuda Hilda Dunsmmore
Rhonda Simmons
Medical officer Department of Health Bermuda Cancer &
Health Centre
28-Feb-12
Belize Natalia Largaespada Beer Laura Tucker Longsworth
Maternal, Child Health President
Ministry of Health Belize Cancer Society
9-Mar-13
Cayman Islands
Sook Lee Yin Medical Director Cayman Islands Cancer
Society 11-Mar-13
Dominica Angela C Desabaye Member Dominica Cancer Society 18-Mar-13
Guyana Fiona lLegall General Manager Guyana Cancer Institute 15-Mar-13
Haiti GertySurena Executive Director Groupe de Support Contre
Le Cancer (GSCC) 7-Mar-13
Jamaica Tamu Davidson Medical
epidemiologist Ministry of Health 22-Feb-12
St Kitts & Nevis
Petrinella Edwards Ministry of Health and Social Services
NCD Programme Coordinator
4-Mar-13
St. Maarten Maria Henry NR Ministry Public Health
Social Development and Labor
6-Mar-13
St Vincent & Grenadines
Naomi D Prince Coordinator Family
Planning Programme
Ministry of Health 23-Feb-12
Suriname Grüngberg Antoon NR Ministry of Health 21-Feb-12
ANNEX 2: HPV PREVALENCE STUDIES FROM THE CARIBBEAN IDENTIFIED IN PEER-REVIEW LITERATURE
33
Country
(Year) Study Population HPV prevalence studies results Sources
Barbados
1993 Women with histologically proven genital carcinoma
HPV DNA was identified in 90% of the samples of histologically confirmed carcinoma (n = 20). HPV 16 was present in 65% samples, HPV 33 and 45 were present in 5%
Prussia PR, terSchegget J, Smits HL. W.I Medical J. 1993: 42: 144 – 146.
Belize
2007
Women who respnded to the cervical cancer prevention campaign
The prevalence of high-risk genotypes was 15.6% in a sample of 463 women from general population, 10.1% in those women with normal cytology, 93% in women with HSIL. Most common HPV types are HPV 16, 18, 56 and 52 in study population, HPV 16 and 18 in women with normal cytology and HPV 16, 31, 35 and 58 in women with HSIL
Cathro HP, Loya T, Dominquez F, et al. Human Pathology 2009: 40: 942 - 949
Guyana
2004 - 2008 Indigenous Amerinidian women
Among study sample of Amerinidian women, prevalence of HPV was 19.5% for all women, 11% in women with normal cytology. Most common genotypes were HPV 31, 16 and 52 in women with CINII/III (n=35), and HPV 18, 16, 31 and 39 in the women with invasive cervical cancer (n=9)
Rebecca S. Kightlinger RS, Irvin WP, Archer KJ,et al. American Journal of Obstetrics & Gynecology 2010: 202:626:e1-7
Jamaica
1990 Women who visited an STD clinic in Kingston
HPV was identified in 28.7% of cervical swabs obtained from this study population. The prevalence of HPV was 39% in women 15 to 19 years of age, and gradually decreased with increasing age
Figueroa JP, Ward E, Luthi TE et al. Sexually Transmitted Diseases. 1995, 22(2):114 - 117
1991 - 1993
Women referred for coloposcopy at a health clinic in Kingston
HPV prevlance study revealed the prevalence of three high risk HPV genotypes, 16, 18 and 45 among patients undergoing colposcopy
Rattary C, Strickler HD, Escoffery C et al. Journal of Infectious Diseases. 1996, 173:718 - 721
2003 - 2006
Pregnant women from the Ante Natal Clinic at the University Hospital in Kingston and non-pregnant women from a family practice in Western Jamaica
HPV presence was identified in 87.7% of the study population, with a higher prevalence in the pregnant study participants. In addition, pregnant study participants also had the highest prevalence for high-risk HPV and multiple HPV infections
Watt A, Garwood D, Jackson M et al. Infectious Agents and Cancer, 2009, 4(Suppl 1):S11
2010
Sexually-active women who attended a selected public or private primary health clinic in one of the four health authority regions
HPV prevalence for any genotype was 54%. Oncogenic HPV genotypes were found in 34.9% of the total study population, and predominant HPV genotypes included HPV 16 , 35, 62, 83, 61, 58, 84, 18, 66 and 81. Oncogenic HPV were found in30.6% of women who had a normal cytology test and 84% of women with abnormal cytology test were HPV positive.
Lewis-Bell K, Luciani S, Unger ER et al. Rev PanamSaludPublica. 2013;33(3):159–65
34
Suriname
1992 - 1994; 1992 - 1995
Women with newly diagnosed invasive cervical lesions from Surinam and the Netherlands
HPV prevalence was 82% in 258 women with malignant cervical lesions (n=130). HPV 16 and 18 were the most common genotypes. Differences in HPV prevalence among three ethnic groups were not observed.
Krul EJT, Van de Vijver MJ, Schuuring E et al. Int J. Gynecol. Cancer 1999, 9:206 - 211
Trinidad and Tobago
2004 Women from the general population
HPV was detected in 35.4% of cancer-free subjects (n = 212). Among the women with positive HPV test, 57.3% carried at least one high-risk HPV genotype. In addition, 33% of these women had multiple HPV infections. HPV 45 and 16 were the pre-dominant types
Ragin CRR, Wheeler VW, Wilson JB et al. Biomarkers. 2007, 12(5):510 - 522
2007
Women who attended three primary health care centers in the northern part of Trinidad
HPV prevalence was 40.6% for both low-risk and high-risk HPV. In addition, 65.9% of HPV positive women were infected with high-risk HPV. HPV 52, 66 and 16 were the predominant genotypes
Andall-Brereton GM, Hosein F, Salas RA et al. Rev PanamSaludPublica. 2011 Apr;29(4):220 - 226
2012
Women with invasive cervical squamous cell carcinoma from public health institutions and private practices
HPV was identified in 91.8% of the samples. Most common HPV genotypes were 16 (66.1%) and 18 (17.8%).
HoseinF,Mohammed W, Zubach V et al. Rev PanamSaludPublica. 2013;33(4):267 – 270
35
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